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When Obamacare passed Congress, Democrats tried to balance competing interests and minimize winners and losers. Once it's repealed, Republicans will have to do the same thing.

It's not clear that they can.

They'll try, but unless their replacement covers as many newly insured people as Obamacare, everyone who benefits from more paying customers will be hurt — and hospitals and other health care providers are bracing for the biggest hit.

Expand chart

The Obamacare tradeoffs:

  • Insurers had to cover more expensive patients, but they were also rewarded with new, paying customers.
  • Hospitals got cuts in their payments, but they also got more insured patients.
  • Drug companies had to pay new fees, but in return, Democrats didn't go after them on drug prices.

The Trumpcare tradeoffs:

  • When sick people gain coverage, as they do under Obamacare, healthy people pay more to cover the costs -- because that's how health insurance works.
  • And if the new system is better for healthy people, it's probably going to be worse for sick people. Republicans want to cover pre-existing conditions mainly for people who have stayed insured for a long time, to keep them from only signing up when they get sick -- but not everyone can afford to stay insured.

That's why independent health care experts are skeptical of GOP promises of better health care at lower costs for more people. "I don't buy that," said Mark Pauly, a health economist at the University of Pennsylvania.

Making it work: Republicans who have worked on replacement plans think they can minimize the losers, but don't have a lot of specifics. Sen. Bill Cassidy, who wrote one of the leading plans, thinks the GOP should just try to be "fair" to everyone, possibly by giving bigger tax credits to groups with more expensive health needs.

"There's no other answer than fairness," Cassidy said. With Obamacare, he said, "there are clear winners. And there are clear losers ... So if we're fair to everybody, we're OK."

One way to minimize winners and losers: let current Obamacare customers keep their coverage and subsidies as long as they need it, and only switch to the new system when they're ready, according to James Capretta, a conservative health care expert who has worked on replacement plans.

And a lot of problems could be solved if insurers have more flexibility in the benefits they offer, according to Chris Condeluci, a consultant and member of the Axios board of experts.

If people can buy more basic, lower-cost plans than they can under Obamacare, more people might sign up and coverage might actually increase, said Condeluci, who was a Senate Republican aide during the passage of Obamacare.

Republicans do want to simplify the benefits, but it's not clear whether they'll "grandfather" the Obamacare coverage -- so the impact on the other health care sectors could be hard to control.

Why hospitals are worried: Take Chicago as an example. John Jay Shannon, chief executive officer of the Cook County Health & Hospitals System, says his hospitals needed $481 million in local taxpayer funds in fiscal year 2009. This year, it only needed $111 million.

Overall, most hospitals came out ahead under Obamacare, with big reductions in uncompensated care costs -- though hospitals in states that didn't expand Medicaid had less relief than hospitals in expansion states. Here's a chart that shows the difference.

"For the first time in the history of this safety net organization, we're taking care of a majority insured population," Shannon said. If newly insured people lose their coverage, he said, his hospitals will need more state and county funding again -- and they probably won't be able to get it.

Go deeper

45 million Americans under winter storm watches near New England

Computer model projection showing the winds moving around the powerful East Coast storm on Saturday Jan. 29, 2022. Image: https://earth.nullschool.net

Nearly 45 million Americans are under winter weather alerts and warnings from North Carolina to northeastern Maine Thursday night, as a major winter storm threatens the region.

Why it matters: It is predicted to be the biggest blizzard since 2018 to strike the Northeast with more than 2 feet of snow possible in parts of eastern Massachusetts, according to the National Weather Service.

Judge nixes Gulf of Mexico oil leases in climate-focused ruling

Tug boats prepare to tow the semi-submersible drilling platform Noble Danny Adkins through the Port Aransas Channel into the Gulf of Mexico on December 12, 2020 in Port Aransas, Texas. Photo: Tom Pennington/Getty Images

A federal judge on Thursday canceled the Biden administration's late 2021 sale of new oil-and-gas drilling leases in the Gulf of Mexico.

Why it matters: The ruling that the greenhouse gas emissions analysis by the Interior's Bureau of Ocean Energy Management (BOEM) was insufficient is a win for green groups that challenged the decision, as they seek to curb fossil fuel production.

5 hours ago - World

Zelensky questions U.S. warnings of "imminent" invasion in Biden call

Biden and Zelensky at the White House last October. Photo: Brendan Smialowski/AFP via Getty

President Biden and Ukrainian President Volodymyr Zelensky had a back-and-forth in their call this evening about just how "imminent" the threat of a Russian invasion might be, according to three sources briefed on the call.

Why it matters: Biden has said previously that he believes Russian President Vladimir Putin will probably "move in" to Ukraine, and White House press secretary Jen Psaki said Thursday afternoon that "an invasion could come at any time."